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SHOULD TRIPTANS BE CONTRAINDICATED FOR MIGRAINES WITH NEUROLOGICAL SYMPTOMS?

PHILADELPHIA — A study by a Houston neurologist questions whether triptan therapy should be contraindicated for patients who experience headaches complicated with neurological symptoms.

Discussing his findings at the AAN Annual Meeting here in May, Ninan Mathew, MD, Director of the Houston Headache Clinic in Texas, said: “There is no proof that neurological symptoms due to complicated migraine are due to ischemia. In fact, new neuroimaging, neurophysiological, and genetic studies indicate that these symptoms are neurological events and not ischemic. If that is the case, then triptans should be safe.

To test his hypothesis, Dr. Mathew and colleagues from the Houston Headache Clinic treated 24 patients with complicated migraines with triptan therapy, and observed them closely for worsening of neurological symptoms.

Ten patients had already been exposed to triptans and had been referred to the clinic for a second opinion regarding their continued use. Investigators gave triptans to the 14 remaining patients.

Of the 24, 11 had basilar migraine; four had hemiparietic migraine; three had familial complex neurological symptoms with migraine (ataxia, hemiparesis, speech abnormalities, and deafness); three had migraine with dysphasia; and three experienced extracephalic cutaneous allodynia – a condition in which a normally painless stimulus is perceived as painful – during attacks. Oral triptans were used as early in the attack as possible.

“We did a number of tests to make sure there was no other underlying reason for these neurological symptoms,” Dr. Mathew said. Tests included magnetic resonance imaging, EEG, and blood work for other causes of ischemia, such as systemic lupus, anticardiolipin antibodies, serum cholesterol, and lipid levels. Patients were asked to stop smoking and to stop taking birth control pills to ensure there were no other complications.

Patients were instructed to take their medication early in the attack, as soon as possible after the onset of the first headache symptoms. If a patient was still experiencing neurological symptoms at the time of the attack, they were told to take their medication anyway.

“We found that patients who took these medicines early not only had relief of their headache, but their neurological symptoms became less prolonged,” Dr. Mathew said. “The earlier you could administer them, the better they did. In fact, the average duration of neurological symptoms fell from 4.2 hours to 1.5 hours. Cutaneous allodynia was completely prevented in all three patients with those symptoms.”

In addition, significantly more patients in this study were pain-free after two hours when compared with patients in previous studies who were instructed to take their medicine later, when the migraine was already full-blown. “The neurological symptoms for these patients did not worsen. They actually became better,” Dr. Mathew said. “We recommend that the contraindications for triptans in complicated migraines be re-evaluated.”

But what about the risk of neurological symptoms? “We can only say from this study that the mechanism of their neurological symptoms may not be ischemic. We need to do further studies to elucidate this further. We are now planning to give triptans to a patient and will measure their basilar artery diameter by doing transcranial Doppler measurements.”